TWilliam2019
Guru
1. Abdominal aortagram /pelvi angiogram
2. Right lower extremity Arteriogram
3. Selective second order catheter placement in right SFA/popliteal artery via left femoral artery access
4. Placement of 6 mm spider filter in the right popliteal artery
5. Balloon angioplasty of the right SFA, SFA stents , and proximal popliteal artery with regular 5 mm balloon and 6 mm DCB
6. Right SFA stent x3drug eluting stents and regular self-expanding stent.
7. tPA thrombolysis of the right TP trunk and peroneal artery
8. Ultrasound-guided percutaneous access of left common femoral artery.
9. Radiologic supervision and interpretation of all of the above.
10. Closure of left common femoral access with 6 French Mynx device
Procedure Details:
After consent was obtained the patient was taken to the operative suite and laid in the supine position. The patient was placed under monitored anesthesia care and bilateral groins were prepped and draped in the usual sterile fashion. A proper timeout was performed and agreed upon by all parties present. Ultrasound was used to gain access to the left common femoral artery.
Ultrasonographic findings: The left common femoral artery is patent without significant atherosclerotic disease. Ultrasound guidance demonstrate successful cannulation of the common femoral artery and intraluminal needle placement. Ultrasound was used to evaluate potential access sites for patency. The target vessel was then accessed under real-time ultrasound guidance verifying intravascular needle entry. Images are stored in the chart.
A wire was passed into the left external iliac artery and a 5 French sheath was placed and flushed with heparinized saline. Universal flush catheter was guided over 0.035 wire into the abdominal aorta and an abdominal aortogram was performed.
AORTOGRAM FINDINGS:
The abdominal aorta is patent. The celiac and superior mesenteric arteries fill with contrast. The right renal artery is patent. The left renal artery is patent. The right common iliac artery is patent. The right external iliac artery is patent. The left common iliac artery is patent. The left external iliac artery is patent. The right internal iliac artery is patent. The left internal iliac artery is patent all the stented vessel showed calcification with atherosclerotic disease without focal significant stenosis.
To improve imaging, the catheter was moved to the level of the aortic bifurcation and arteriogram performed. The right common femoral artery and profunda femoral artery is patent. The right superficial femoral artery is occluded starting mid third to the distal third including the SFA stent with multiple collaterals around the occlusion supplying the distal reconstitution at the proximal popliteal artery. The left common femoral artery and profunda femoral artery is stenosed . The left superficial femoral artery is patent.
The universal flush catheter was guided over the aortic bifurcation into the right common femoral artery and a rightlower extremity arteriogram was performed.
RIGHT LOWER EXTREMITY ARTERIOGRAM FINDINGS:
The common femoral artery is patent.
The profunda femoral artery is patent.
The superficial femoral artery is occludedoccluded starting mid third to the distal third including the SFA stent with multiple collaterals around the occlusion supplying the distal reconstitution at the proximal popliteal artery
The popliteal artery is patent.
The anterior tibial artery is occluded.
The tibioperoneal trunk is patent
The posterior tibial artery is occluded.
The peroneal artery is patent.
Systemic heparin was given and allowed to circulate, multiple ACT were drawn to maintain ACT level above 250 the entire operation the patient required 13,000 units of IV heparin the sheath was exchanged for a 6 French by 45 cm sheath and flushed with heparinized saline.
I performed another completion angiogram, which confirmed complete occlusion of the right SFA from the mid third to the distal third including occlusion of the previously placed 6 mm stent based on the ultrasound and angiography, I I was able successfully to cross the occlusion without a difficulty therefore I thought most likely patient has subacute to chronic thrombus that is organized now that caused occlusion. Therefore I decided to place a filter to prevent distal embolic event 6 mm spider filter was placed in the right popliteal artery. Successfully without any complication. Followed by balloon angioplasty the right SFA from mid third to the distal third including the SFA stents with starting 5 mm x 150 mm balloon regular balloon then we performed 6 mm x 150 mm DCB balloon t then followed by completion angiogram which showed 70 to 80% resolution of the in-stent occlusion with the SFA proximal to the previously placed SFA stents showed residual stenosis and area of dissection and most likely the culprit because the thrombosis of his right SFA and the SFA stents therefore I decided to cover that area of dissection and make an overlap with the previously placed stent about 1 cm successfully I was able to deploy the 6 mm x 120 mm self-expanding drug eluting stent and then postdilated with 5 and 6 mm balloons the completion then I actually captured the spider filter I removed , out of the body and I I inspected the filter and there was a significant sized plaque with a thrombus in his and the filter therefore after that I decided to do another completion angiogram to see if there is any residual stenosis in the right SFA previously placed stent which is located at the distal third of the right SFA, which continue to show residual stenosis more than 30% and thrombus at the proximal stent therefore I decided to place another filter in the right popliteal artery, and I placed 2 mg of tPA for thrombolysis in the popliteal and the peroneal artery to prevent any clot showering distally. At this point I decided to placement of 6 mm x 100 mm Eluvia stent and postdilated with 6 mm regular balloon the completion angiogram after all of the show robust flow through the right SFA and complete residual stream of any in-stent stenosis and exclusion of the thrombus. Runoff through the peroneal artery was patent and supplying both posterior tibial and anterior tibial however there was no formed pedal dorsal arch.
At this point however crossed the sheath and pulled back and Contrast injection through the sheath showed no access site complications. The access site was closed with an 6 French Mynx closure device, the sheath was removed and non-occlusive pressure was held on the left femoral artery for 5 minutes per protocol. Following this, there was no bleeding or hematoma. A sterile dressing was applied.
2. Right lower extremity Arteriogram
3. Selective second order catheter placement in right SFA/popliteal artery via left femoral artery access
4. Placement of 6 mm spider filter in the right popliteal artery
5. Balloon angioplasty of the right SFA, SFA stents , and proximal popliteal artery with regular 5 mm balloon and 6 mm DCB
6. Right SFA stent x3drug eluting stents and regular self-expanding stent.
7. tPA thrombolysis of the right TP trunk and peroneal artery
8. Ultrasound-guided percutaneous access of left common femoral artery.
9. Radiologic supervision and interpretation of all of the above.
10. Closure of left common femoral access with 6 French Mynx device
Procedure Details:
After consent was obtained the patient was taken to the operative suite and laid in the supine position. The patient was placed under monitored anesthesia care and bilateral groins were prepped and draped in the usual sterile fashion. A proper timeout was performed and agreed upon by all parties present. Ultrasound was used to gain access to the left common femoral artery.
Ultrasonographic findings: The left common femoral artery is patent without significant atherosclerotic disease. Ultrasound guidance demonstrate successful cannulation of the common femoral artery and intraluminal needle placement. Ultrasound was used to evaluate potential access sites for patency. The target vessel was then accessed under real-time ultrasound guidance verifying intravascular needle entry. Images are stored in the chart.
A wire was passed into the left external iliac artery and a 5 French sheath was placed and flushed with heparinized saline. Universal flush catheter was guided over 0.035 wire into the abdominal aorta and an abdominal aortogram was performed.
AORTOGRAM FINDINGS:
The abdominal aorta is patent. The celiac and superior mesenteric arteries fill with contrast. The right renal artery is patent. The left renal artery is patent. The right common iliac artery is patent. The right external iliac artery is patent. The left common iliac artery is patent. The left external iliac artery is patent. The right internal iliac artery is patent. The left internal iliac artery is patent all the stented vessel showed calcification with atherosclerotic disease without focal significant stenosis.
To improve imaging, the catheter was moved to the level of the aortic bifurcation and arteriogram performed. The right common femoral artery and profunda femoral artery is patent. The right superficial femoral artery is occluded starting mid third to the distal third including the SFA stent with multiple collaterals around the occlusion supplying the distal reconstitution at the proximal popliteal artery. The left common femoral artery and profunda femoral artery is stenosed . The left superficial femoral artery is patent.
The universal flush catheter was guided over the aortic bifurcation into the right common femoral artery and a rightlower extremity arteriogram was performed.
RIGHT LOWER EXTREMITY ARTERIOGRAM FINDINGS:
The common femoral artery is patent.
The profunda femoral artery is patent.
The superficial femoral artery is occludedoccluded starting mid third to the distal third including the SFA stent with multiple collaterals around the occlusion supplying the distal reconstitution at the proximal popliteal artery
The popliteal artery is patent.
The anterior tibial artery is occluded.
The tibioperoneal trunk is patent
The posterior tibial artery is occluded.
The peroneal artery is patent.
Systemic heparin was given and allowed to circulate, multiple ACT were drawn to maintain ACT level above 250 the entire operation the patient required 13,000 units of IV heparin the sheath was exchanged for a 6 French by 45 cm sheath and flushed with heparinized saline.
I performed another completion angiogram, which confirmed complete occlusion of the right SFA from the mid third to the distal third including occlusion of the previously placed 6 mm stent based on the ultrasound and angiography, I I was able successfully to cross the occlusion without a difficulty therefore I thought most likely patient has subacute to chronic thrombus that is organized now that caused occlusion. Therefore I decided to place a filter to prevent distal embolic event 6 mm spider filter was placed in the right popliteal artery. Successfully without any complication. Followed by balloon angioplasty the right SFA from mid third to the distal third including the SFA stents with starting 5 mm x 150 mm balloon regular balloon then we performed 6 mm x 150 mm DCB balloon t then followed by completion angiogram which showed 70 to 80% resolution of the in-stent occlusion with the SFA proximal to the previously placed SFA stents showed residual stenosis and area of dissection and most likely the culprit because the thrombosis of his right SFA and the SFA stents therefore I decided to cover that area of dissection and make an overlap with the previously placed stent about 1 cm successfully I was able to deploy the 6 mm x 120 mm self-expanding drug eluting stent and then postdilated with 5 and 6 mm balloons the completion then I actually captured the spider filter I removed , out of the body and I I inspected the filter and there was a significant sized plaque with a thrombus in his and the filter therefore after that I decided to do another completion angiogram to see if there is any residual stenosis in the right SFA previously placed stent which is located at the distal third of the right SFA, which continue to show residual stenosis more than 30% and thrombus at the proximal stent therefore I decided to place another filter in the right popliteal artery, and I placed 2 mg of tPA for thrombolysis in the popliteal and the peroneal artery to prevent any clot showering distally. At this point I decided to placement of 6 mm x 100 mm Eluvia stent and postdilated with 6 mm regular balloon the completion angiogram after all of the show robust flow through the right SFA and complete residual stream of any in-stent stenosis and exclusion of the thrombus. Runoff through the peroneal artery was patent and supplying both posterior tibial and anterior tibial however there was no formed pedal dorsal arch.
At this point however crossed the sheath and pulled back and Contrast injection through the sheath showed no access site complications. The access site was closed with an 6 French Mynx closure device, the sheath was removed and non-occlusive pressure was held on the left femoral artery for 5 minutes per protocol. Following this, there was no bleeding or hematoma. A sterile dressing was applied.
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